- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.85 / $34.85 / $42.60
| Professional | | $34.85 | $34.85 | $42.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.44 / $128.26 / $202.29
| Facility | | $108.44 | $128.26 | $202.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.09 / $54.22 / $63.11
| Professional | | $46.09 | $54.22 | $63.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.23 / $44.23 / $54.64
| Facility | | $44.23 | $44.23 | $54.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.60 / $37.60 / $54.64
| Professional | | $37.60 | $37.60 | $54.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.43 / $38.43 / $38.43
| Facility | | $38.43 | $38.43 | $38.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.02 / $39.11 / $130.38
| Professional | | $25.02 | $39.11 | $130.38 |